The Australian Transport Safety Bureau (ATSB) is Australia's national transport safety investigator. The ATSB's function is to improve safety and public confidence in the aviation, marine and rail modes of transport. The ATSB is Australia's prime agency for the independent investigation of civil aviation, rail and maritime accidents, incidents and safety deficiencies.

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Media release

Title

ATSB Response to WA Coroner's Findings on VH-SKC Accident

Date: 12 September 2002

The ATSB is pleased that Coroner Hope has adopted much of the
material in ATSB's final report on the tragic VH-SKC accident and
stated that "ultimately it appears that the ATSB report was based
on a substantial amount of scientific investigation and many issues
were diligently pursued" (p21). The Coroner also cites (eg p6) the
evidence of Dr Brock who was a consultant to the ATSB and part of
the ATSB investigation team.

The Coroner concludes (p55) that: "It appears that the aircraft
was unpressurised for a significant period of its climb and for the
subsequent flight. While it is possible that the occupants died as
a result of hypobaric hypoxia, I cannot exclude the possibility
that some unknown and unidentified toxic fumes caused their
incapacity and death".

The ATSB final report (p29) conclusion was very similar: "Due to
the limited evidence available, it was not possible to draw
definitive conclusions as to the factors leading to the
incapacitation of the pilot and occupants of VH-SKC.� The aircraft
was probably unpressurised for a significant part of its climb and
cruise for undetermined reasons. The pilot and passengers were
incapacitated, probably due to hypobaric hypoxia, because of the
high cabin altitude and their not receiving supplemental
oxygen."

ATSB reported that testing established that carbon monoxide and
hydrogen cyanide were unlikely to have been factors - there was no
evidence of another toxic substance.

The WA Coroner has also supported the safety recommendations
that the ATSB had either already made or had proposed in
submissions and that is very welcome.

While an investigation report into a remote 440km/h impact crash
and subsequent fire which destroys much of the evidence is always
open to criticism, based on its initial reading of the 75 page
report, the ATSB does not accept the Coroner's criticisms
concerning the ATSB.

The ATSB cannot prepare an investigation report that is suitable
for an adversarial legal process because this is contrary to its
'no blame' legislation based on Annex 13 to the Chicago Convention.
The proposal to share investigation information with those who may
use it in blame proceedings also has limitations. The Coroner,
police or regulators could have undertaken their own parallel
inquiries for such purposes.

The ATSB investigation report was prepared to satisfy the
Bureau's Commonwealth legislation (which it did), not to satisfy
the WA Coroner or any other parties who may have had an agenda
related to blame or litigation. The ATSB nevertheless provided
extensive expertise at its expense to assist the Coroner during the
Inquest.

The Coroner criticises the ATSB for deficiencies and delays with
the forensic tests done in Brisbane - however, coroners not ATSB
have control/powers with respect to autopsies and forensic testing.
The ATSB relies on coroners to authorise the conduct of such
testing and has no powers to do so itself. Improving cooperation
with coroners in relation to sharing evidence is a key element of a
memorandum of understanding currently under discussion with
coroners across Australia. Coroner Hope's final remark (p75) that
"The various Coronial jurisdictions clearly have a role to play in
this context to ensure that sensible co-operation can take place."
is welcome.

The Coroner's criticism (pp 9-10) of the letter written by the
ATSB Executive Director to the Coroner on 26 March 2002 (copy
attached) is noted. The letter was written and sent only after the
Executive Director had obtained legal advice that it would be
appropriate to do so given that the Inquest was in the nature of an
inquiry.

The Bureau is deeply concerned at the personal criticism
directed towards its senior Perth-based investigator (pp17ff). It
does not agree that there is evidence to conclude that the
investigator "demonstrated an unfortunate lack of compassion for
grieving families who were searching for answers." The investigator
had the difficult job of finalising the investigation report after
several staff had resigned/retired from the Bureau and had to face
aggressive cross-examination.

The Coroner refers to the Transport Safety Investigation Bill
2002 that is before the Commonwealth Parliament and suggests that
this may need to be amended. This Bill has been extensively
discussed with representatives of the Coroners and their
suggestions have been incorporated. There is positive and helpful
ongoing discussion with Coroners on draft regulations and a future
memorandum of understanding.